Study Aids

ABOUT THIS RESOURCE

This resource helps you prepare for the Medical Council of Canada’s clinical skills exam, the MCCQE Part II, and equivalent exams in other countries, such as the USMLE Step 2 in the United States.

It aims to offer a concise, strategic approach to the exam, based on common entities as the likely targets for the exam and the practical limits of what standardized patients can play.

THE CLINICAL PRESENTATIONS IN THIS RESOURCE

The clinical presentations in this resource come from the objectives for the exam set by the Medical Council of Canada (MCC). (The MCC publishes its clinical presentations online under its “medical expert” objectives: use the search term Medical Council of Canada medical expert in your browser.)

The resource unpacks each clinical presentation in a series of standard sections.

MCC PARTICULAR OBJECTIVE(S)

The MCC outlines a particular focus for most of its clinical presentations, which this section summarizes.

MCC DIFFERENTIAL DIAGNOSIS WITH ADDED EVIDENCE

The MCC lists causal conditions for each clinical presentation, which are presented in this section as an edited and expanded differential diagnosis.

The differential diagnosis is edited (lightly) to exclude uncommon entities.

It is expanded to describe the common presentations of the remaining entities (except where, occasionally, these entities are self-explanatory and need no expansion).

So, this section presents the common clinical evidence for the common entities in the MCC’s list of causal conditions.

The MCC notes in each clinical presentation that its list of causal entities is not exhaustive. These lists do, however, show the MCC’s priorities for the exam—which is why this resource follows them closely.

STRATEGY FOR PATIENT ENCOUNTER

This section describes the elements likely to shape a patient encounter for each clinical presentation, including the likely scenario and the likely tasks. The tasks can include history, physical exam, investigations, or management. Most clinical presentations could engage any of these tasks, so generally this part covers all of them each time.

In clinical presentations where the MCC identifies emergency management as the focus, the resource unpacks steps for emergency management.

This section also sometimes includes “pearls”: particular advice gleaned from experience in clinical practice.

HOW THIS RESOURCE HELPS YOU OVERCOME COMMON CLINICAL-EXAM ERRORS

The Medical Council of Canada reports several common clinical- exam errors, including:

• not recognizing urgent presentations
• peppering patients with closed-ended, yes-no questions
• not listening for, or looking for, evidence to rule out differential diagnoses
• counselling patients with rote, directive, generic information

This resource helps you overcome these common errors by:

• summarizing the MCC’s objectives for each clinical presentation, which highlight when urgent presentations are at issue, and unpacking steps in emergency management where relevant
• modelling open-ended questions
• clarifying diagnostic goals for history taking, physical exams, and investigations
• modelling approaches to counselling that target the particular situation of patients and enable them to make their own, informed decisions

EXAM BASICS

EXAM FORMAT

You can read about the format of the MCCQE Part II on the MCC’s website.

The exam takes place over 2 days and involves a series of encounters with standardized patients. An examiner is present during each encounter (you should ignore the examiner, except when the examiner speaks to you).

The first day has 8 14-minute encounters.

The second day has 4 6-minute encounters combined with 6-minute reading or written-answer tasks (the encounters may come before or after the reading or written-answer tasks).

Any clinical presentation can form the focus of either kind of encounter.

The use of standardized patients places some strategic constraints on the exam. For example:

• Only people age 16 and older can play standardized patients. So, in pediatric cases, the patient will likely be an adolescent, a child absent on some pretext (leaving the parents to discuss the concern), or a simulated neonate.
• Psychiatric disorders are easier to simulate than disorders with physical symptoms, which increases the likelihood of a psychiatric disorder on the exam.

OVERALL GOAL: FIND EVIDENCE, USE EVIDENCE

Your overall goal is to gather evidence, and use this evidence to focus on what is relevant and useful to the individual case at hand.

READ THE CASE INSTRUCTIONS CAREFULLY

Each patient encounter begins with a set of written instructions that describe a scenario and specify the tasks you need to perform.

You have 2 minutes to go over these.

• Glean context from the instructions. For example, they may contain laboratory test results, or information about the patient’s age or occupation, which may be relevant to the differential diagnosis.
• Do only the tasks specified by the instructions.
• If an instruction says to “assess” a patient, start by taking a history. Do a physical exam only if warranted by the evidence.

ALWAYS TAKE THESE FIRST STEPS

Always:

• Introduce yourself to the patient.
• Ask the patient for consent to interview and examine them. Be aware that consent may depend on culturally sensitive care, which the patient may not clarify until you ask.
• Offer the patient a chaperone for the encounter.
• Wash your hands.

USE HISTORY TAKING TO HELP THE PATIENT TALK

Standardized patients have information to tell you that is designed to narrow your differential diagnosis. Use open-ended questions, as opposed to yes-no questions, to let the patient talk.

And then listen.

MAKE NOTES SPARINGLY

You will be supplied with a pen and paper at the exam (you’re not allowed to bring your own). You can use these for notes during history taking, but keep your focus on your patient.

Make eye contact with the patient as they talk. If you take notes, be strategic—for example, sum up distinguishing symptoms or red flags with single words.

TALK YOUR WAY THROUGH PHYSICAL EXAMS

Describe your procedures and findings as you perform a physical exam, including normal findings. This allows the examiner to understand your process.

Always:

• Obtain the patient’s permission to conduct a physical exam.
• Drape the patient appropriately.

FOCUS ON RELEVANT INVESTIGATIONS

Order investigations that narrow the differential diagnosis, based on evidence from the scenario instructions, the history, and/or the physical exam. Don’t order every possible investigation.

TAILOR MANAGEMENT TO THE PATIENT

Provide next steps and information that target the situation of the particular patient. This means you need to ask the patient for relevant details about their situation, such as work, recreation, and dietary routines. Think of these details as a way to begin a conversation with the patient about changes to their routines that could help them.

LISTEN FOR REDIRECTION WHEN YOU’RE STUCK

There may be times that you blank on a scenario, or nerves get in your way. If you are seriously off track, the examiner may try to redirect you. Be aware of attempts at redirection and adjust your approach accordingly.

If you draw a blank on history taking, remember that you can always ask about medications, allergies, family and personal medical history, and the psychosocial impact of the presenting problem.

PREPARE FOR PARTICULAR CHALLENGES

PATIENTS WHO REQUIRE CULTURALLY SENSITIVE CARE

Any patient encounter may engage the need for culturally sensitive care. When you ask permission to interview and examine a patient, a refusal from the patient may stem from this.

When a patient withholds consent, engage in a straightforward, respectful conversation about the patient’s expectations for care.

For example:

• Express confidence in your ability to help the patient.
• Describe specific procedures and investigations you may need to perform in the context of the patient’s case.
• Ask the patient how to proceed with their permission (e.g., by providing a same-sex doctor).
• Do your best to meet the patient’s expectations while protecting the patient’s health and safety.

PATIENTS WHO ARE RELUCTANT TO TALK

Some standardized patients may show reluctance to talk, to test your ability to elicit information on sensitive topics. In these situations:

• Acknowledge the patient’s reluctance to talk (e.g., “It seems like you are having some difficulty talking about your health concern.”)
• Offer empathy and reassurance (e.g., “Some problems are hard to talk about. It’s okay to feel unsettled. I want to help you, not judge you.”).
• Express confidence in your ability to help the patient.
• Show your ability to listen respectfully: allow the patient to talk at their own pace.

ABUSIVE PATIENTS

Some standardized patients may be angry. In these situations:

• Remain calm.
• Acknowledge the patient’s anger.
• Express confidence in your ability to help the patient.
• Ensure your safety and the safety of others. It may be appropriate to assess for homicidal ideation (e.g., “When someone is as upset and angry as you are, they sometimes think about harming others. What thoughts have you had about harming others?”). Seek an emergent admission to a psychiatry ward in the case of homicidal ideation.
• Offer clear next steps. For example, state that you need the patient to answer some questions, so you can better understand their situation.

NONCOMPLIANT PATIENTS

The health concerns of some standardized patients may stem from noncompliance with prescribed medications.

For example, uncontrolled diabetes can contribute to a variety of presenting problems, such as incontinence, hypertension, and diplopia. Patients may have uncontrolled diabetes because they are not taking their medication, due to forgetfulness or financial constraints.

In any noncompliant patient, seek the reasons for noncompliance.

• In forgetful patients, discuss possible strategies to help with compliance. For example, how could they set up reminders for themselves? How well do they cope with day-to-day tasks in general? What family or friends could they call on for assistance? In patients who are not coping and who do not have social supports, consider community supports such as home care services.
• In patients who cannot afford their medications, express empathy and seek details about the patient’s situation. Consider referring the patient to social service agencies, which can help with financial assistance and skills such as budgeting.

DISSENTING HEALTH-CARE PROFESSIONALS

The exam may test your ability to manage conflict with other health-care professionals who disagree with your decisions about a patient’s care. Use evidence to negotiate these situations:

• Take a position based on evidence, and defend it calmly and rationally.
• Offer to monitor the patient’s situation and revisit your decisions as the evidence warrants.

INTRODUCTION

“I got in!”

These are three of my favourite words, and I am fortunate to hear them quite regularly from the medical-school applicants I work with directly. I wish I could hear them even more than I already do. This is part of what has led me to write this resource: the idea that more students might benefit from the information, perspectives, and strategies that other applicants to medical school have found useful.

I hope this resource gives support and encouragement to your dreams of becoming a physician, and concrete ideas and strategies for success in a challenging process. I hope it will, in some small way, help you be the next one to say: I got in!

WHY THIS RESOURCE?

If you’re reading this resource, you are likely already aware of how challenging the process of admission to a Canadian medical school can be. If you are like many applicants, you may have already tried applying on your own, without success.

You are not alone. Most medical-school applicants I see have extremely high grade point averages, not to mention extracurricular and community activities galore. They tend to apply to many medical schools, yet receive only one or two interviews—if any. Many of the accomplished students who have sought my help are on their second or third application attempt.

How can this be?

I believe part of the answer lies in numbers. There are ninety-six universities in Canada with a total student population of about 1.8 million. Not every student hopes to become a physician, of course, but take a moment to think about how many students you know in high school or university who are thinking about medical school. When I worked at orientation fairs for incoming students to first-year university, the question I got most from students and parents was: Can you tell me what courses we need to get into medical school?

So, there are potentially lots of interested students. We have limited numbers of medical schools in Canada and limited numbers of spots available at each school. This means that the posted “minimum requirements” from medical schools don’t necessarily reflect the reality of a successful application in Canada.

When I visited a Caribbean medical school several years ago, I spent a week with several premedical advisors from the United States. As the only Canadian advisor, I was startled to hear some of the statistics that my American counterparts told me represented their students: grade point averages in the low 2s (out of 4), and entrance exam scores far lower than any I had seen in my daily work at a Canadian university.

I thought to myself: If the students I worked with had similar statistics, I could understand why they didn’t receive offers of admission. But their statistics were much better—even among students who were applying to Caribbean medical schools because they felt they couldn’t compete with applicants to Canadian medical schools.

The students I have seen in the last twenty years have, by an overwhelming majority, strong academics and good test scores, and contribute enthusiastically, consistently, and broadly in their larger communities. Yet, less than fourteen percent of applicants to medical school received offers in 2015–2016 in Ontario. This percentage appears to be similar across Canada.

In my experience, most medical-school hopefuls—whether they are in high school or university—are used to setting difficult goals and achieving them. The goal of admission to medical school, or the perceived “failure” to achieve it (if you have applied before), can present the biggest challenge you have ever faced. I have seen this challenge erode the confidence of the most stellar students, but I have also seen those students and many others persevere and succeed.

WHY THIS AUTHOR?

I’d like to tell you a bit about why I think I can help.

Over the last twenty years working as a career advisor at a Canadian university, I have worked with thousands of students, from first-year undergraduates to PhD candidates, in diverse degree programs from fine arts to engineering physics. My work has involved helping undergraduate and graduate students explore career options, consider related degree decisions, strategize about further education, search for jobs, and improve their career-development knowledge and skills.

During this time—in my university job and, since 2007, in my private practice—I have also worked with thousands of students hoping to become physicians. I have an “insider” perspective on the health sector from a wide range of experience. For example, for eight years, I volunteered as a community member on a medical-school admissions committee, where I reviewed applications and interviewed candidates. I was not involved in selecting candidates, and I do not speak for medical schools or their selection criteria (particularly since admissions procedures have evolved since my committee work), but I did screen many candidates and came to recognize qualities that, in my judgement, made some candidates stand out. I have also developed and delivered hundreds of workshops on applying to, and interviewing for, medical school and residency programs, and have spent eighteen years working with final-year medical students and international medical graduates applying to residency programs.

So, I offer you:

• experience as someone who has read thousands of medical-school applications and coached thousands of students through application strategies and medical-school interviews (in my private practice, I have given personalized coaching to a hundred or so students—all, except one, have succeeded in getting accepted to medical school)
• knowledge of the processes, terminology, and challenges of medical school and residency programs
• stories of applicants who have struggled and ultimately succeeded in their goals
• twenty years of coaching students to medical school and residency placements
• career-counselling techniques to help you present yourself as an informed and focused applicant, and to develop crucial backup plans

And I offer you the experience of hundreds of thousands of hours working with students just like you.

However, I want you to be skeptical of any secondhand source (and that includes me and a long list of others: medical students, doctors, advisors, guidance counsellors, parents, and helpful books and friends). Only the medical schools themselves, in the year that you plan to apply, have the most current and accurate information or interpretation of a given “rule.” Be wary of people or sources (websites, campus clubs, mentoring groups) that make definitive statements about “rules”: the rules come from processes that continually evolve. Every “expert” (including me) is filtering information through their own lens. We are merely interpreters and not the source. Make sure that you are getting the information that you need and can trust. That means always validate what you hear, read, see, or suspect from the source—in other words, from the people who will take your application money and decide your future in their program.

To be clear: the source is each medical school in the year you plan to apply.

Repeat this to yourself! Chant it whenever you are tempted to take shortcuts and assume that someone else knows what they are talking about.

For example, your question might be, Does my human geography course count as a humanities prerequisite for medical school? The “expert” answer of a secondhand source is always: Blah, blah, blah, blah, blah. They might sound very sure of themselves as they answer your question—but what you should hear, especially with a question that asks them to interpret what a medical school wants, is blah, blah, blah, blah, blah.

You can listen to what the person says, and think of it as possibly true, but always remember it is only one perspective. You need to verify the information directly from the medical school itself. Yes, this means more work for you, but it is really important work to do. Pretend a patient’s life is at stake, because it is: you are the patient in this case.

This resource and other people will help you get information and ideas that can be very useful in your process. You can incorporate some of those views and advice (and mine) into your strategy. But always, always remember that what is true for them, and true for now, might not be true for you or true when you apply.

I wrote this resource less as a “do this, do that” manual and more as a “think about this, think about that” strategy tool. This is my biggest gift to you: a strategy to find your own “insider” perspective, which, in my experience, has produced the most confident and competent applicants in the end.

WHY START IN HIGH SCHOOL?

While my primary client base is university and postgraduate students, I do work with some high school students. I wanted to include them in this book because I believe that starting earlier in the process (without overly stressing our students) can be a helpful way to pace out an application to medical school, review additional career options, and ultimately have a less difficult and more successful application process, if and when the time comes around. This resource has a specific chapter for high school students, but also many additional strategy suggestions throughout.

WHY INCLUDE PARENTS?

In my experience, parents and other supporters often play a large and vital part in encouraging medical-school hopefuls, so that’s why I have included a chapter for them in this resource. If you are a parent, or have a parent or supporter who is aware of your medical- school hopes, take a look at chapter 17. I hope it gives parents strategies to help support students embarking on this process, as well as some information about what students might be facing as they do so.

If you are a student with well-meaning parents or supporters, I suggest leaving that chapter lying casually open somewhere, in a place they might trip over it. They want to help you and this might be a good start.